Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need Participating Provider Non-Participating Provider Important Information (You will pay the least) (You will pay the most) does not apply through exception process. If you have Facility fee (e.g., ambulatory 15% coinsurance Not covered Prior authorization required. outpatient surgery surgery center) Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. Emergency room care 15% coinsurance 15% coinsurance None If you need Emergency medical 15% coinsurance 15% coinsurance None immediate medical transportation attention $45 / visit, deductible does not Non-Participating Providers covered when Urgent care apply. Not covered temporarily outside the service area: $45 / visit, deductible does not apply. Facility fee (e.g., hospital 15% coinsurance Not covered Prior authorization required. If you have a room) hospital stay Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. If you need mental Outpatient services $25 / visit, deductible does not Not covered None health, behavioral apply. health, or substance Inpatient services 15% coinsurance Not covered Prior authorization required. abuse services Depending on the type of services, a No charge, deductible does not copayment, coinsurance, or deductible may Office visits apply. Not covered apply. Maternity care may include tests and services described elsewhere in the SBC If you are pregnant (i.e., ultrasound). Childbirth/delivery 15% coinsurance Not covered None professional services Childbirth/delivery facility 15% coinsurance Not covered None services If you need help Home health care 15% coinsurance Not covered 130 visit limit / year. Prior authorization recovering or have required. other special needs Rehabilitation services Outpatient: $35 / visit, Not covered Outpatient: 60 visit limit / year. Prior 12024_1983-101_KWNX_SBC-W-LG-DED-XX_{666604}_{WP24 - WA PEBB DHMO}_912202315325 Rev. (11/16) Page 3 of 6